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Archived: Ryecroft Private Residential Care Home Inadequate

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Inspection report

Date of Inspection: 26 June 2014
Date of Publication: 1 August 2014
Inspection Report published 01 August 2014 PDF | 84.07 KB

The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care (outcome 16)

Meeting this standard

We checked that people who use this service

  • Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety.

How this check was done

We looked at the personal care or treatment records of people who use the service, carried out a visit on 26 June 2014, observed how people were being cared for and talked with people who use the service. We talked with carers and / or family members, talked with staff, reviewed information given to us by the provider and talked with commissioners of services.

Our judgement

The provider had an effective system to regularly assess and monitor the quality of service that people received.

The provider had an effective system in place to identify, assess and manage risks to the health, safety and welfare of people who used the service and others.

Reasons for our judgement

There was no registered manager post at the time of our visit. A new manager had been appointed and commenced employment at the home in March 2014. The new manager had recently submitted an application to the Care Quality Commission to become the registered manager of the home. The application was still in progress at the time of our visit.

We asked to see evidence of the quality monitoring systems that ensured the health, safety and welfare of people who lived at the home. We were shown evidence that some systems were in place. An external health and safety audit was completed in August 2013 by the company used by the home in respect of health and safety advice and management. We saw that an action plan was in place and that the provider was working towards compliance with this action plan. The provider was involved in risk assessing and auditing aspects of health and safety around the home for example, conducting fire risk assessments, a general internal audit every four months and the completion of a home audit. These audits identified and managed the hazards and repairs in the home’s environment.

We saw that the provider had undertaken an inspection of the home's bedrooms in March 2013. The provider told us these had been reviewed in September 2013. We also saw that a general environment audit was completed in February 2014. We noted that where actions had been identified they had been completed. The provider may find it useful to note however that some of the audits for example, the home inspection audit were over 9 months old. This meant there was a risk that they could be out of date.

We saw evidence that the provider had audited a sample of the home’s care plans and the quality and safety of the service in relation to housekeeping, catering, medication and staffing arrangements in January 2014. We found that where issues had been identified these had been acted upon and completed. The provider may find it useful to note however that it was unclear how often this audit was completed by the provider in order to ensure the quality of the service provided.

The audits we reviewed were inconsistent in terms of frequency. We spoke to the manager about this. They said they were currently looking at the audits in place and showed us the new medication audit they had recently introduced. They also told us about their plans to introduce additional health and safety audits (called customer path audits) and regular care plan audits to ensure care files continued to contain accurate and up to date information about people’s needs and care.

We were told by the provider that they visited the home on a weekly basis to check the quality of the service and to support the manager with the management of the home. They told us they did a visual inspection of the home to check for cleanliness, any repair and maintenance issues and talked to people about the care they received at the home. The manager confirmed that weekly meetings took place and showed us their handwritten notes from the meetings held with the provider. The provider also provided evidence after the inspection with regards to the topics discussed and management actions agreed. The provider may find it useful to note however that there were no formal records relating to the provider’s visual inspection and discussions held with the people who lived at the home in relation to their care.

We saw that accident and incident information was logged in people’s care files and recorded on an accident/incident form in the manager’s office. We asked the manager how accident/incident information was analysed to identify any trends for example in the type of falls or location so that the home could learn from accidents/incidents and take appropriate action. The manager advised that no formal accident/incident audits were currently undertaken. This meant no learning from accidents or incidents was utilised to prevent similar incidents happening in the future